Traditional Medicines and Traditional Healers in South Africa

Discussion paper prepared for the Treatment Action Campaign and AIDS Law Project

Marlise Richter Researcher: AIDS Law Project richterm@law.wits.ac.za 27 November 2003

Executive Summary Traditional healers have a crucial role to play in building the health system in South Africa and strengthening and supporting the national response to HIV/AIDS. This paper sketches a background to traditional healing in South Africa and discusses international policies, guidelines and the South African legal framework on traditional health practitioners. It argues for the regulation of traditional healers and traditional medicine, as well as for the application of human rights principles within the traditional healing profession. The paper concludes with advocacy strategies and ways of aligning traditional healing with a human rights framework.

Table of Contents Introduction_______________________________________________ 4 What is Traditional Medicine?______________________________ 7 Who draws on Traditional medicine and how prevalent is its use?__________________________10 Why is there a tension between traditional medicine and Western medicine?______________________________12 Are there any known effective traditional medicines for the treatment of HIV/AIDS?_______________________ 16 How are traditional healers regulated? _____________________19 How are traditional medicines regulated? __________________ 21 Where to from here?______________________________________ 23 Conclusion _______________________________________________ 25 Advocacy strategies ______________________________________ 26 Aligning Traditional Healing and Human Rights: A Checklist__________________________________________ 29 Appendix A_______________________________________________ 30 Appendix B _______________________________________________31 Appendix C_______________________________________________ 34 Appendix D_______________________________________________ 37 Appendix E_______________________________________________ 39 Appendix F _______________________________________________47

Zimbabwe healer moots magic chastity potion

A ZIMBABWEAN healer wants to promote the use of a traditional spell that ensures fidelity, alongside the more conventional methods of condoms and abstinence to curb the spread of Aids in the country. Healer Mutsa Chikede came up with the idea of using a technique that involves magically "locking" women and immobilising men, to bar them from having extra-marital sex, alongside condoms and abstinence because the latter only have a limited impact on stemming the spread of Aids in Zimbabwe. Around one in four of Zimbabwe's adult population is infected with the HIV virus, and Aids kills an average of 3 000 people in the country each week. Chikede's proposed technique uses traditional herbs to cast a spell that can be administered by a healer even in the absence of the subject. It has become popularly known in Zimbabwe as the "central locking system," or "immobiliser". When applied, the spell is supposed to ensure that one cannot have sex outside marriage. - Mail & Guardian 10 October 2001

The popular media in South Africa often carry horror stories of traditional medicine and its practitioners, while sensationalist articles have escalated with the rise of the AIDS epidemic. Reports of the prescription of mysterious herbal treatments or muti, healers who claim to have found the cure for AIDS, and unethical and unsavoury behaviour relating to treatment of patients can

often been be found in the pages of newspapers or magazines.1 While a number of traditional healers have thoroughly deserved the negative publicity generated by their disreputable conduct, these stories may have contributed to a negative sentiment held towards all traditional healers and to all traditional healing practices. This has meant that the role that ethical and well-educated traditional healers can play in South Africas response to HIV/AIDS and its efforts to build up its health system has largely been ignored.

This paper will set out several of the issues and controversies that surround traditional healing in South Africa and the African continent at large many of which have been crystallised and propounded by the crises brought on by HIV/AIDS. It will give an overview of the systems of traditional healing, its principles and practitioners, while keeping a focus on traditional healers management of HIV/AIDS. It will briefly discuss the legal framework that is proposed by the Traditional Health Practitioners Bill, while also looking at international policies and guidelines set out by organisations such as UNAIDS, the World Health Organisation (WHO) and South Africas Medical Research Council (MRC).

This paper will argue for the inclusion of traditional healers in South Africas response to HIV/AIDS. It will also argue that more resources should be channelled towards research into the efficacy and safety of traditional medicines. In its conclusion, this paper will provide recommendations on how traditional healers can be included into the activities of government, nongovernmental organisations (NGOs) and community-based organisations (CBOs) in the response to HIV/AIDS, as well as to set out advocacy strategies

See for example H. Mulaudzi Traditional AIDS healer silenced City Press, 31/01/2000; and V. Mchunu and P. Leeman Inyanga claims he has cure for AIDS Mercury 01/02/200.

on aligning the traditional healing profession with basic human rights principles.

The purpose of this paper is to assist the AIDS Law Project and the Treatment Action Campaign (TAC) in developing a more sophisticated view of traditional healers and traditional medicine based on a better understanding of the sector. This paper is written from the perspective of a human rights, HIV/AIDS and gender researcher and not from an anthropological viewpoint. I accept that there be omissions and would welcome and invite any comments to remedy these.

What is Traditional Medicine?

The WHO observes that it is difficult to assign one definition to the broad range of characteristics and elements of traditional medicine, but that a working definition is essential. It thus concludes that traditional medicines:

[Include] diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness.2

In this paper, the terms traditional3 and Western medicines and practitioners are frequently used. With the employment of these terms, I

Traditional Medicine Strategy 2002-2005, World Health Organization, WHO/EDM/TRM/2002.1, Geneva, p.7. The WHO draws a distinction between traditional medicines and complementary and alternative medicines. The latter terms relate to practices such as acupuncture, homeopathy and chiropractic systems thus a broad set of health care practices that are not part of a countrys own tradition, or not integrated into its dominant health care systems (ibid). For a study of the use of the role of complementary and alternative medicines in HIV/AIDS, see R. Crouch, R. Elliot, T. Lemmens and L. Charland Complementary/Alternative Health Care and HIV/AIDS: Legal, Ethical & Policy Issues in Regulation Canadian HIV/AIDS Legal Network, 2001. 3 The term traditional medicine will refer to the traditional medicine in Sub-Saharan Africa.

would like to acknowledge that they are awkward, politically-loaded and rather unhelpful in describing the principles, philosophy and practices they represent. It is problematical to assign sensitive and precise definitions to these terms, while no synonyms are readily available.

One of the definitions given for African Traditional Medicine by the WHO Centre for Health Development is the following:

The sum total of all knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental, or societal imbalance, and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing.4

Western medicine or biomedicine is often contrasted with the approach taken by traditional medicine practitioners as described above. The former is usually associated with diseases of the physical body only, and are based on the principles of science, technology, knowledge and clinical analysis developed in Northern America and Western Europe.

Biomedical literature refers to the use of traditional medicines as

phytotherapy. Traditional medicine and traditional healers form part of a

broader field of study classified by medical anthropologists as ethnomedicine.5 In South Africa, most people associate traditional medicine with the herbs, remedies (or muti) and advice imparted by sangomas or izinyangas

Planning for cost-effective traditional medicines in the new century a discussion paper WHO Centre for Health Development. Accessible: http://www.who.or.jp/tm/research/bkg/3_definitions.html 5 Mark Nichter writes that ethnomedicine entails a study of the full range and distribution of health related experience, discourse, knowledge, and practice among different strata of a population; the situated meaning the aforementioned has for people at a given historical juncture; transformations in popular health culture and medical systems concordant with social change; and the social relations of health related ideas, behaviors and practices from Anthropological approaches to the study of Ethnomedicine M. Nichter (ed.) Tucson, Arizona: Gordon and Breach Science Publishers, 1992, p.ix.

traditional healers from African indigenous groups and with strong spiritual components.

Traditional healers are generally divided into two categories those that serve the role of diviner-diagnostician (or diviner-mediums) and those who are healers (or herbalists).6 The diviner provides a diagnosis usually through spiritual means, while the herbalist then chooses and applies relevant remedies.7 Colonial powers and structures have played an overpowering role in changing the cultural landscape and practices of traditional healers and their patients and have disrupted the distinction between diviners and herbalists. The Jolles brothers write that various pieces of legislation (such as the Witchcraft Suppression Act of 1957 and the Witchcraft Suppression Amendment Act of 1970) explicitly prohibited the diviners from practicing their trade as early as 1891 in colonial Natal.8 With the additional encroachment of Western health care systems in South Africa on the practice and livelihood of traditional healers, the roles of the diviner and herbalist have become increasingly blurred.9 Traditional healers are thus undergoing a strange process of mutation as the continent modernizes.10 In

addition, I would argue that the AIDS epidemic constitutes a considerable part of the modernising forces that constantly challenge and change traditional healers role and their practices.

Increasing efforts have been made regionally and internationally to include traditional healers in primary health care, as well as in HIV/AIDS care and prevention. A range of difficulties and opportunities thus present themselves

F. Jolles and S. Jolles Zulu Ritual Immunisation in Perspective in Africa 70 (2), 2000, p.230 and M. Steinglass It takes a village healer Anthropologists believe traditional medicines can remedy Africas AIDS crisis. Are they right? Lincua Franca April 2002, p.32. 7 Jolles op cit, p.237. 8 Jolles op cit, p.239. 9 Jolles op cit, p.241-242. 10 Steinglass op cit, p.37.

in this inclusion and will be discussed later in this paper. I include two examples below:

Steinglass writes that traditional healers tend to take a holistic approach [to illness], treating the patients spiritual and physical well-being together. With a terminal disease like AIDS, the spiritual side becomes very important.11 Munk, on the other hand, remarks on the role that traditional healers play in the psychological well being of patients:

[The traditional healers in her study in Kwa-Zulu Natal] had not received the particular communicative skills that are important in counselling when dealing with patients that might be HIV-positive. It is usually considered redundant or maybe even culture imperialistic to provide healers with counselling skills because one anticipates that there is already a valid discourse inherent in the traditional healing system. What has to be realized, however, is the fact that a ritual of divination, in which all diagnosis takes place, is a highly dramatic event where everything is presented to the patient in a point-blank way. The shock effect is a crucial part of the ritual arrangement, and even though this might be a splendid way of doing things when it comes to revelations of ancestral wrath or witchcraft, it produces consequences when an AIDS-educated healer suddenly states a cogent description of this new disease and the lack of a cure.12

It is important to note that some NGOs and other institutions have recognised the important role that traditional healers can play in providing counselling and support, and have initiated training in counselling for traditional healers. Certain branches of the counselling NGO Lifeline have provided workshops

11 12

Steinglass op cit, p.32. K. Munk Traditional healers and HIV/AIDS in KwaZulu-Natal: an interim report AIDS Analysis Africa (Southern African Edition), 8(5), Feb/March 98, p.7.

and training to traditional healers that focused on basic counselling skills, personal growth and HIV/AIDS awareness.13

Who draws on Traditional medicine and how prevalent is its use?

The WHO estimates that up to 80% of the population in Africa makes use of traditional medicine.14 In Sub-Saharan Africa, the ratio of traditional healers to the population is approximately 1:500, while medical doctors have a 1:40 000 ratio to the rest of the population.15 It is clear that traditional healers play an influential role in the lives of African people and have the potential to serve as crucial components of a comprehensive health care strategy.

The WHO formally recognised the importance of collaborating with traditional healers in 1977.16 It has organised a number of expert consultations and conferences, and has issued guidelines on traditional medicines, traditional healers and collaboration between biomedicines and traditional medicines. Because traditional medicines use biological resources and knowledge of traditional groups, it is often linked to biodiversity conservation and indigenous peoples rights over their knowledge and resources.17

In various countries, traditional healers have been drawn on in primary health care strategies before the advent of HIV/AIDS. With rapidly escalating HIV prevalence rates in Sub-Saharan Africa, it is foreseeable that peoples

Telephonic interview with Ms. Hanlie van der Vyfer, Chairperson LifeLine Pretoria, 20 November 2003. 14 Traditional Medicine Strategy 2002-2005 op cit., p.1. 15 Abdool Karim SS, Ziqubu-Page TT, Arendse R. Bridging the Gap: Potential for a health care partnership between African traditional healers and biomedical personnel in South Africa (supplement) SAMJ 1994; 84 s1-s16 as quoted by Colvin et al in Integrating traditional healers into a tuberculosis control programme in Hlabisa, South Africa AIDS Bulletin, March 2002, p.29. 16 Steinglass op cit., p.32. 17 K. Timmermans Intellectual property rights and traditional medicines: policy dilemmas at the interface Social Science and Medicine Aug. 2003, Vol. 57, Issue 4, p.745. [From the abstract].

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expectations of traditional healers and the subsequent workload of traditional healers are dramatically increasing. Many of the delegates at a conference held to review the effect of traditional healers on HIV prevention and care, noted that in view of its widespread use, traditional medicine is in a real sense carrying the burden of clinical care for the AIDS epidemic in Africa.18 It would thus follow that traditional healers need the support, education and cooperation that formal health care systems might be able to offer, while the latter could potentially expand the reach and efficacy of their HIV prevention and treatment programmes by enlisting the help of traditional healers.

It is difficult to estimate how many South Africans make use of traditional healers and how many traditional healers practice their trade. While a number of other African countries have made early attempts to formally recognise traditional healers and to set up traditional healer organisations, the South African government has only recently embarked on this process notably with the drafting of the Traditional Health Practitioners Bill. The first province-wide traditional healers council was only established in 1999.19

The Traditional Healers Organisation (THO) is the biggest traditional healer umbrella organisation in South Africa and was established in 1970.20 It counts 69 000 traditional healers in Southern Africa as its members, with 25 000 of those residing in South Africa. Traditional healers who intend to join the THO have to attend a one-day workshop, which introduces them to THO activities, and a five-day workshop on traditional primary health care. Members also have to produce a good character reference. At the moment the THO has provincial branches in Mpumalanga, Limpopo, KwaZulu-Natal and the North
G. Bodeker, D.Kabatesi, R.King and J.Homsy Lancet, Vol.355, April 8, 2000, p.1284. The conference brought together 100 delegates from 17 African countries and was held in Kampala, Uganda. 19 K. Morris Policy and People. Treating HIV in South Africa a tale of two systems Lancet Vol. 357, No.9263, 14 April 2001. It was established in KwaZulu-Natal. 20 Telephonic interview with Ms. Madonna Hodges, THO Operations and Support Manager, 26 September 2003.
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West province, while the head office is located in Johannesburg. The South African Traditional Healers Health Care Group is another example of an umbrella body of traditional healers. It has a number of branches over South Africa, and focus specifically on home-based care, Direct Observation Treatment (DOT) support for people with TB, Voluntary Counselling and Testing, education on HIV/AIDS and street counselling.21

Why is there a tension between traditional medicine and Western medicine?

Friction is evident between Western medicines or biomedicines that look at material causation to understand and treat an illness; and traditional medicine that generally looks towards the spiritual origin such as witchcraft and displeasure by ancestors in order to cure an ailment.22 There has been an array of media reports of traditional healers claiming to have a cure for AIDS or submitting their patients to dangerous or ineffective treatments.23

Munk writes that some traditional healers view HIV/AIDS as a development of an old disease that can be treated by TH [Traditional healers] only. 24 Conditions such as ilumbo, umeqo and ncunsula exhibit the same type of symptoms as AIDS-related illnesses, while their origins are said to be found in bewitchment and infidelity. These can be cured by traditional healers by
Telephonic interview with Mr. David Ngaleka, President: South African Traditional Healers Health Care HIV Group, 6 November 2003. Interview conducted by Ms. Mosa Seloane. 22 F. Jolles and S. Jolles op cit , p.238. The Jolles brothers study focuses on Zulu traditions, but I think the discord between biomedicine and traditional medicines can be applied more broadly. For a more in-depth study of the connections between HIV/AIDS and witchcraft see A. Ashforth An Epidemic of Witchcraft? The Implications of AIDS for the Post-Apartheid State African Studies, 61(1), 2002, pp.121-143. 23 The ALP has received some enquiries and complaints about traditional medicine and traditional healers. An example of a complaint is traditional medicine that was advertised as Miracle Muti that is the closest thing to curing HIV/AIDS; and an enquiry about company employees going to traditional healers and not receiving sick certificates when they were too ill to go to work. The ALP also assisted in a case of traditional healer who fraudulently promised people that he will cure them of HIV/AIDS in return for the payment of a high fee in Fourways, Johannesburg. The man was charged with contravening the Medicines and Related Substances Control Act. Interview with Ms. Chloe Hardy, AIDS Law Project Paralegal Officer, 25 September 2003 For details of the latter case, see Police nab alleged scam healer, Mail & Guardian, 12 July 2003. 24 K. Munk op cit p.7.
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purgative methods and enemas, which facilitate the polluting essence to leave the body. If the symptoms are gone, then the patient is considered cured.25 Amongst some people in Africa, it is believed that if a sick person does not obtain treatment and dies, his spirit will cause further disease.26 It is important to take note of the fact that traditional healers, traditional medicine and belief systems of sickness and health can vary according from region to region, and from clan to clan.

A number of traditional healers have seen a lucrative opportunity of curing people living with HIV/AIDS (PWAs) from HIV/AIDS, in the absence of a cure by biomedicine and where a number of developing countries have not been able to provide anti-retroviral medication or adequate health care to those living with HIV/AIDS. Two case studies are offered to illustrate the AIDS opportunism or AIDS entrepreneurship displayed by some traditional healers:

ibid P. Baguma The traditional treatment of AIDS in Uganda: benefits and problems. Keys issues and debates: traditional healers Societes dAfrique et sida 1996, Jul (13). [Quote from the abstract].
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Case Study I

Zeidan Hammad is an internal-medicine specialist at the CHU-Tokoin hospital, the main hospital in Lome. The hospital does not treat AIDS patients. There is nothing we can do for them here he says If theyre rich, they go off to Europe. If theyre poor, we send them home to die. Its not entirely true that the hospital can do nothing. Hammad can treat the opportunistic infections that attack AIDS patients in the early stages of HIV infection, and if their immune systems have not deteriorated too badly, he can prolong their lives. And this is where Hammads frustration with traditional healers manifests itself. I have people come to me with problems that suggest they may be HIV positive, and I tell them, go get tested and then come back he says. And they disappear for six months. I go to the test lab and ask, what happened to this person? And they say, yes, we tested him. Then suddenly six months later the person shows up in my office again, practically on the point of death. And he says, Oh, I tested HIV positive, so I went to traditional healer, but it didnt work. So I went to another healer, but didnt work either. So now theyre back, and now I cant do anything for them. Its too late. Educated people! And they go to those healers. Its crazy!27

27

The case study is an extract from the Steinglass article op cit, p.34.

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Case Study II

The major cities in the province [of KwaZulu-Natal], Durban and Pietermaritzburg, have recently seen the appearance of new traditional hospitals, where the patients are treated by TH [traditional healers] only. On admission the patient is diagnosed in a divination ritual in which bones are thrown. Through the pattern of the bones the ancestral spirits will reveal the patients ailment and general condition. If the patient suffers from AIDS the treatment will cost R800, and it is clearly stated that only opportunistic infections will be treated. The new traditional hospitals are eager to establish an identity that resembles the Western medical system and the distinction between treatment and cure is therefore pronounced. Some of the healers have been influenced by Western religious new-age thinking and have diplomas in homeopathy. The nurses are young women in white uniforms. They have been given a first aid course. On taking a walk through the ward it seemed as if most of the patients were suffering from full-blown AIDS in the terminal state, and were so weak that couldnt even reach out for a glass of water. There was no help from the nurses, who had ensconced themselves behind the glass wall to the staff room. To my great surprise I learned from the director that the hospital didnt have any AIDS patients at the time. All these dying people were instead suffering from amagobongo (ancestral wrath because a very rare ritual of puberty hadnt been performed), amandawo (a kind of spiritual possession), imimoya (a kind of witchcraft that attacks the brain) and

ukutwasa (a sign that the patient is chosen by the ancestors to become a traditional
healer.

They had all been discharged from the ward of internal medicine at Edenvale [hospital in Pietermaritzburg], because Western-trained doctors couldnt help them there.28

The case study is an extract from the Munk article op cit, p.8. While I take exception to the authors tone and terminology used, as well as doubt some of the points that she presents as facts (for example, that she diagnosed the patients in the hospital as terminally-ill PWAs from merely looking at them and that she knew that all the patients had come from Edenvale), I regard the scenario she describes as a useful example of the potential pitfalls of AIDS opportunism.

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It is vital to note that not all traditional healers approach HIV/AIDS in the way described above. Yet, these case studies cast some light on why certain traditional healers receive negative publicity, why many medical doctors may be frustrated with traditional healers and their practices, how the HIV/AIDS epidemic has been translated into traditional healer language, symbolism and procedures and why many people may regard traditional healers in an unfavourable and/or suspicious light.

Are there any known effective traditional medicines for the treatment of HIV/AIDS?

The MRC established a South African Traditional Medicines Research Unit, which has strong links with a number of departments at the University of Cape Town. Their areas of activity include registration of provisional patents, research into various medicinal plants (with a particular focus on anti-TB and anti-Malarial drug research) and research training of postgraduate students.29 One of their joint ventures was the creation of a Traditional Medicines Database called TRAMED III in 2000. In 1997, this Unit first produced a practical guidebook for traditional healers in Primary Health Care principles.30 This was done in consultation with various traditional healer groups, and the initiative supports the South African National Drug Policy, which emphasises the rational and safe use of medicines, including traditional medicines.31

I corresponded with a staff member of TRAMED III on the question of whether any traditional medicines in South Africa have clinically been proven to be effective in the treatment of HIV/AIDS. He replied that there was none that

See www.mrc.ac.za/traditionalmedicines/highlights.htm T.Felhaber and I. Mayeng South African Primary Health Care Handbook Combining Western and Traditional Practices Cape Town: CopyCat Communicastions, 1999 (revised edition). 31 Ibid, p.i.
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he was aware of.32 The chair of Global Initiative for Traditional Systems (GIFTS of Life), an international organisation that is particularly active in attempts to formally recognise traditional medicines, also informed me that he did not know of any clinical data of an African treatment for HIV-related illnesses, but assured me that studies were underway.33 He did however direct me to a clinical study on herpes zoster done in Uganda. In this study, PWAs treated with herbal products at clinics of indigenous healers (the healer patients) experienced similar rates of resolution of their herpes zoster compared with the control group that received either symptomatic treatment or acyclovir34. Herpes zoster-related pain resolved substantially faster among the healer patients.35

I also came across a Zimbabwean study that assessed the quality of life of PWAs, where some were treated with traditional medicines (79%) and others with conventional medical care (21%). The study used the WHOQol instrument36 to determine the quality of life of the subjects, while it also measured disease progression. The study concluded that its data support the role of phytotherapy in improving the quality of life of HIV-1 infected patients, yet its pharmacological basis is unknown.37

E-mail correspondence with Dr. Gilbert Motlalepula Matsabisa on 18 September 2003. E-mail correspondence with Dr. Gerhard Bodeker, Chair: GIFTS of Life, University of Oxford on 18 September 2003. 34 Acyclovir is an antiviral medication used to treat shingles, chicken pox, herpes and other viral diseases. 35 Homsy J, Katabira E, Kabatesi D, Mubiru F, Kwamya L, Tusaba C, Kasolo S, Mwebe D, Ssentamu L, Okello M, King R. Evaluating herbal medicine for the management of Herpes zoster in human immunodeficiency virus-infected patients in Kampala, Uganda. Journal of Alternative and Complementary Medicine 2000 Feb;6(1):1-2. The conclusion of the study reads as follows: Herbal treatment is an important local and affordable primary health care alternative for the management of herpes zoster in HIV-infected patients in Uganda and similar settings. [From abstract] 36 WHOQol stands for World Health Organization Quality of Life project. The aim of the project is to develop indicators and instruments to assess Quality of Life that is applicable internationally and cross-culturally. For more information on the Project, see http://www.acpmh.unimelb.edu.au/whoqol/aboutProject.html 37 M.B Sebit, S.K. Chandiwana, A.S Latif, E. Gomo, S.W. Acuda, F. Makoni and J. Vushe Quality of Life evaluation in patients with HIV-1 infection: the impact of traditional medicine in Zimbabwe Central Journal of Medicine Aug 2000, 46 (8), pp. 208-213. Quotation from abstract. The study is described as a community based open label non-intervention and uncontrolled cohort study.
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Dr. Bodeker referred me to the director of Phyto Nova (PTY) Ltd, a South African company that researches, promotes and distributes natural traditional medicines from indigenous African plants. In correspondence with Dr. Nigel Gericke about studies under way of traditional medicine for treatment of HIV/AIDS, I learnt about a product called Sutherlandia, which has apparently shown a very positive impact on the quality-of-life of PWAs.38 Phyto Nova notes that they have found that over 4000 patients with HIV/AIDS who are not on anti-retroviral therapy, but use Sutherlandia39 have shown an improvement in appetite, exercise tolerance, mood, sense of well-being, while most wasted patients show a weight increase within 6 weeks of starting the treatment.40 Phyto Nova makes it clear that these observations are not a substitute for a clinical trial and need to be validated and quantified by an independent controlled clinical trial.41 Studies done by the MRC, showed no toxicity. Dr Gericke notes that the MRC promised a pilot trial, but we heard nothing since.42 This may be indicative of the apathy or antipathy with which mainstream medical organisations regard traditional medicine.

At a conference held in Nairobi on the traditional medicines and HIV/AIDS in Africa, it was pointed out that in two or three decades of medicinal plant research in Africa have not lead to the development of a single medicine

E-mail correspondence with Dr. Nigel Gericke, Phyto Nova (Pty) Ltd Founder and Director, 18 September 2003. 39 Also known as Unwele, Cancer Bush or Kankerbos. 40 Phyto Novas Sutherlandia briefing document. Available from author and Dr. Nigel Gericke, p.2. In the Lancet article on traditional medicines (14 April 2001) op cit, Sutherlandia frutescens, is described as a herbal immunomodulator which has proven anti-cachexia and anti-HIV actions. 41 Phyto Novas Sutherlandia briefing document op cit. p.2. 42 E-mail correspondence with Gericke op cit. In our correspondence, Dr. Gericke also wrote the following: I think it is an incredible tragedy that we have had no official support or recognition for the potential of the work we are doing. A months supply of treatment can cost as little as R13.68; In the interest of affordability and accessibility we deliberately did not take a proprietary position on our lead products, and even encouraged competition by freely making info and seeds available. All our plants used in our products are cultivated, leading to conservation of bioresources, and also to job creation. Fortunately this work is being taken more seriously overseas. A combination of simple available nutrition, cheap vitamins and minerals and Sutherlandia can undoubtedly extend life for years. We have 30 doctors using our product, and all is based on word of mouth; we spend not a cent on marketing. I am not at all satisfied by anecdotal reports of efficacy, but to date we have had zero success in three years of looking for funds for a trial in South Africa.

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being produced for national distribution.43 The WHO describes the problems related to clinical data on traditional medicines in the following way:

The quantity and quality of the safety and efficacy data on traditional medicine are far from sufficient to meet the criteria needed to support its use worldwide. The reasons for the lack of research data are due not only to health care policies, but also to a lack of adequate or accepted research methodology for evaluating traditional medicine. It should also be noted that there are published and unpublished data on research in traditional medicine in various countries, but further research in safety and efficacy should be promoted, and the quality of the research improved.
44

A model protocol for controlled clinical evaluation of traditional remedies for HIV/AIDS has been developed that might be of assistance in the provision of such data.45 In particular, the urgency of establishing the efficacy of traditional medicine was noted by the Nairobi conference delegates. They emphasised the importance of establishing efficacy [of traditional medicine] as quickly as possible. They argued that the emphasis should not be on sideeffects when hundreds of people are daily dying from AIDS and malaria that may be curable.46

How are traditional healers regulated?

As have been noted before, South Africa is lagging behind other African countries in recognising traditional medicine and establishing structures for

43

Traditional medicine and HIV/AIDS in Africa a report from the International Conference on Medicinal plants, Traditional Medicine and Local Communities in Africa) - A Parallel session on the Fifth Conference of the Parties to the Convention of Biological Diversity, Nairobi, Kenya, 16-19 May 2000. The Journal of Alternative and Complementary Medicine, Vol. 6, No. 5, 2000, p.464. 44 Traditional Medicine Strategy 2002-2005, World Health Organization op cit, p.22. 45 See R.R Chaudhury A Clinical Protocol for the Study of Traditional Medicine and Human Immunodeficiency Virus-related Illness The Journal of Alternative and Complementary Medicine Vol. 7, No.5, 2001, pp. 553-566. 46 The Journal of Alternative and Complementary Medicine, 2000 op cit, p.467.

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traditional medicine and traditional healers. (See Appendix A for a table of African countries that have established traditional medicine structures, budgets and training in traditional medicine.)

The only government initiative on regulating traditional healers that I could find is the Traditional Health Practitioners Bill of 2003.47 This proposed piece of legislation aims to

Provide for the establishment of the Interim Traditional Health Practitioners Council of the Republic of South Africa; to provide for a regulatory framework to ensure the efficacy, safety and quality of traditional health care services; to provide for control over the registration, training and practice of Traditional Health Practitioners and to provide for matters incidental thereto.48

It defines traditional health practice quite broadly and gives the following definition to a traditional health practitioner a person registered or required to be registered in terms of this Act and includes a traditional birth attendant49 and a traditional surgeon50. The proposed Act sets out a number of objects

and functions of the proposed Traditional Health Practitioners Council of South Africa (the Council),51 while its general powers would include, inter alia, registering people as traditional health practitioners, establishing registers for various traditional health practitioners and making rules to further the objects of the Act.52

As published in Government Gazette No. 24704, Vol. 454 on 11 April 2003. Notice 979 of 2003. Preamble of the Bill. 49 Defined as a person who attends at and assists with the birth of a child or who assists and advises pregnant women or women who have just given birth concerning prenatal, perinatal and postnatal matters. 50 Defined as a person who performs circumcision as part of an African cultural initiation ceremony. 51 Section 5 of the Bill 52 Section 6
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It is foreseen that the Council will have of a maximum of 25 members and will consist of registered traditional health practitioners, a representative from the Department of Health, someone from a legal background, a medical practitioner of the Health Professions Council of South Africa (HPCSA), and others.53 The Council will have to meet at least twice a year.54

While a number of sections set out the procedures for the registration of traditional health practitioners, the Bill does not provide details on what the minimum requirements are or what training or practice criteria have to be fulfilled for a person to be regarded as a traditional health practitioner. It leaves it to the Minister to prescribe the necessary qualifications on recommendation of the Council.55 It is important to note that section 19(1) provides that No person shall be entitled to practise [sic] as a traditional health practitioner within the Republic unless he or she is registered in terms of this Act.56 It is foreseen that traditional health practitioners not registered with the Council will not be able to recover remuneration in respect of any act specially pertaining to the occupation of a traditional health practitioner.57 The Bill states that a person who diagnoses, treats or offers to treat, or prescribes treatment or any cure for cancer, HIV/AIDS or such other terminal diseases as may be described shall be guilty of an offence.58

How are traditional medicines regulated?

As far as I could ascertain, traditional medicine has to undergo the same standard procedures and clinical tests for registration as approved medication, as would any other candidate substance. On the 31st of August
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Section 7 Section 11(b) 55 Section 25. 56 Commendably, the Bill starts with all-inclusive language, but lapses to only using the male pronoun in later sections. 57 Section 39 (1). Penalties for such offences are set out in Section 44. 58 Section 44 (1)(g)(i)

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2003, the Medical Control Council (MCC) established a virtual reference centre for traditional medicines called the National Reference Centre for African Traditional Medicines (NRCATM). 59 The Minister of health is to appoint a Management Board for this Centre.

A number of problems present themselves when intellectual property rights discourse and procedures are applied to traditional medicine. In its document, the Protection of the Heritage of Indigenous People, the United Nations (UN) notes that industrial property laws only protect new knowledge and that old knowledge like herbal remedies that have been used for ages, may not be regarded as patentable.60 Delegates at the Nairobi conference argued that the following problems may impede the patenting of some traditional medicines: regional specificity and short duration of patent rights, the issue of biopiracy, the lack of official recognition of community rights (as distinct from those of an individual applicant) and the lack of emphasis on availability and access of local communities to medicinal-plant resources.61 A WHO workshop report on intellectual property rights observes that holders of traditional knowledge often do not have the necessary means or resources to

E-mail correspondence with Mr. Nchele Lentsoane, MCC Complementary Medicine Project on 23 September 2003. Mr. Lentsoane noted that the primary aims and objectives of the NRCATM are: The development of an appropriate and practical regulatory framework for the registration, regulation and control of African Traditional Medicines; The establishment of a database with emphasis on information technology; The promotion of research and development with a bias on issues of standardization and authentication of products from plant extracts using WHO guidelines; The identification of education and training needs of traditional medicine in South Africa; The protection of indigenous knowledge and trade promotion through patents and intellectual property rights ; The propagation and cultivation of medicinal plants in a way that promotes sustainability, job creation and trade. Its mandate is to advance the contribution of African Traditional Medicines to the health and well-being of the people of the region. 60 Protection of the Heritage of Indigenous People, Office of the High Commission for Human Rights, United Nations, New York and Geneva, 1997, p.13. Prepared by Erica-Irene Daes: Special Rapporteur of the Cub-Commission on Prevention of Discrimination and Protection of Minorities and Chairperson of the Working Group on Indigenous Populations. 61 The Journal of Alternative and Complementary Medicine, 2000 op cit, p.467.

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register patents, as it is a very expensive process.62 Bio-prospectors generally do not have contracts with indigenous people, but rather with academic institutions.63 Yet, difficulties with the social impact of paying large sums of money directly to community leaders were noted as the money might increase the traditional leaders power and reduce their accountability to their own people.64 The WHO deals with a number of these concerns, by providing a list of recommendations - see Appendix B for a list of these.

Where to from here?

Traditional healers make a unique contribution that is complementary to other approaches. They also tend to be the entry point for care in many African communities, and even more so for the complex HIV-related diseases that frequently jolt family dynamics and shake community stability. Traditional healers often have high credibility and deep respect among the population they serve. They are knowledgeable about local treatment options, as well as the physical, emotional and spiritual lives of the people, and are able to influence behaviours. Thus, is imperative and practical to consider traditional healers as partners in the expanded response to HIV/AIDS, and to maximize the potential contribution that can be made towards meeting the magnitude of needs for care, support and prevention.65

- Sandra Anderson UNAIDS Intercountry Team E. and S. Africa Pretoria, South Africa

- Noerine Kaleemba UNAIDS Geneva, Switzerland

UNAIDS makes a number of key points in favour of collaboration with traditional healers. Importantly, they note that traditional healers provide

Report of the Inter-regional Workshop on Intellectual Property Rights in the Context of Traditional Medicine, WHO, Bangkok, Thailand, 6-9 December 2000. WHO/EDM/TRM/2001.1, p. 7-8. 63 Protection of the Heritage of Indigenous People op cit., p.12. 64 ibid, p.13. 65 Ancient Remedies, New Disease: Involving traditional healers in increasing access to AIDS care and prevention in East Africa UNAIDS Best Practice Collection June 2002, p.5.

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client-centre, personalised health care that is culturally appropriate, holistic and tailored to meet the needs and expectations of the patient. Traditional healers are culturally close to clients, which facilitates communication about disease and related social issues. This is especially important in the case of STDs.66

It is clear from this paper that a great deal of research and inquiry are needed into traditional medicines and traditional healing with regards to HIV/AIDS in particular A clear focus of further and urgent investigation should be the gendered dimensions of traditional medicine and traditional healing.67 Baguma adds the following topics for enquiry: Steps should be taken to understand the conditions that facilitate the emergence of healers purporting to cure AIDS, the type of clients attracted to these services, and the costs and benefits of traditional medicine, with the ultimate goal of involving traditional healers in ongoing AIDS information, education, and counselling programs68 Yet, it is critical to take into account the work that international organisations like the WHO and UNAIDS have done on traditional healing, as they provide extensive guidance and recommendations on these topics.69 In their evaluation of different projects that facilitate collaboration between medical doctors and traditional healers, UNAIDS has developed Best Practice criteria that can be used effectively for other collaborating initiatives (see Appendix E).
Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa: A Literature review UNAIDS Best Practice Collection September 2000, p.10. See Appendix C for a comprehensive listing of points for and against collaboration with traditional healers. 67 All the literature I reviewed failed to include a gender dimension into their enquiry into traditional healing and its practitioners. It is foreseeable that most traditional healers are male, while UNAIDS notes that women often constitute the majority of traditional healers clients, ibid p.14. Complex gender power dynamics, as well as the obstacles women may face in approaching male traditional healers with Sexually Transmitted Infections (STI) ailments in particular, need further exploration. 68 Baguma op cit, [Quotation from abstract.] 69 See in particular the case study done on Ugandas Traditional and Modern Health Practitioners Together (THETA). Refer to Appendix D. THETA is generally regarded as a thriving example of collaboration between medical doctors and traditional healers in an African setting. Also see the following for further information: Red Cross/ Red Crescent publications: http://www.ifrc.org/publicat/wdr2000/wdrch3b.asp and the Uganda AIDS Commission: http://www.aidsuganda.org/response/govt_sectors/cso_programs/theta.htm
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Conclusion Steinglass observes the following:

If traditional healers believe that diseases are caused by witchcraft, there is not much you can do with them, from a biomedical perspective. They belong, as one doctor who worked in a district hospital in Africa put it, to a system that is irreconcilable with our own. But if traditional healers do not ascribe to sorcery even if they think illnesses are caused by tiny insects, by imbalances in semimystical forces of heat, by interference with the bodys internal snake whatever then you can work with that.70

I would therefore argue that if it is possible for traditional healers to separate out the metaphysical elements from the physical techniques of their trade, and for biomedical doctors to suspend their cynicism and disparagement about traditional healing, that a common ground for collaboration and support will open up. This partnership could play a significant and deeply influential role in Africas response to HIV/AIDS. In this regard, UNAIDS calls for a respectful attitude of open exchange of ideas and information and the need for a common language to be established.71 Yet, it is necessary to heed Paul Farmers warning that a new emphasis on collaborating with traditional healers should not serve as substitute for the Wests failure to provide the worlds poor with decent scientific medical care.72 Seen in this light, a list of recommendations and strategies follow below.

Steinglass op cit, p.36. Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa: A Literature review op cit, p.15 and 22. 72 The quotation is Steinglass paraphrasal of the arguments Farmer makes in his book AIDS and Accusation. Steinglass op cit, p.36.
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Advocacy strategies73

Traditional healers have an unmistakable and crucial role to play in building the health system in South Africa and strengthening and supporting the national response to HIV/AIDS. Due to decades of colonialism, cultural imperialism and the power of multi-national pharmaceutical industry, traditional healers and traditional medicines have been marginalized and their value to communities underplayed. There is therefore a need for urgent investment and support of traditional healers and traditional medicine not only by government, but also by civil society and the private sector. At the same time, it is vitally important that human rights principles and a human rights framework are strictly applied to all aspects of traditional healing.

In view of this, the following advocacy strategies are recommended: All people have the right to medicines and treatment that are safe and efficacious. Medicines, whether Western or traditional, have to fulfil the same uniform standards, tests and trials before being made available to the public. In this regard, it is recommended that the religious, spiritual or metaphysical elements be separated from the physical matter (for example the plant materials) of traditional medicine in order to facilitate the process of testing and approving these medicines for use by the general public; More resources and infrastructure need to be committed to test and promote the use of safe and efficacious traditional medicines, as well as to regulate the traditional healing profession. This will be in keeping with the principles of The New Partnership for Africas Development (NEPAD), that emphasise African ownership and leadership, as well as
73

I would like to thank Nathan Geffen and Mark Heywood from the Treatment Action Campaign for their input on this section.

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broad and deep participation of all sectors of society and partnership between and amongst African peoples.74 African leaders have committed themselves to incorporate the potential of traditional medicine in the processes and strategies of strengthening their health systems.75 The NEPAD Human Resource Development Programme and NEPAD Health Strategy acknowledges the historical lack of attention given to traditional healing,76 and proceeds to outline the development and strengthening of traditional medicine as one of the NEPAD health strategic directions (see Appendix F for the NEPAD strategy) It is vital that the traditional healing profession be regulated and be brought into the ambit of current legislation. All practicing traditional healers should adhere to standardized norms and qualifications. To this end, the speedy passing of the Traditional Health Practitioners Bill should be supported; No medical or traditional healing practitioner may be allowed to overstate or misrepresent the efficacy of their medicines or treatment, and these should be strictly regulated; There is a need for a campaign that raises awareness of the rights of patients to adequate care, treatment and support by traditional healers. Unscrupulous traditional healers must be reported and disciplined by a regulating body; It is important to review the literature on the effects of taking traditional medicines in conjunction with Western medicines prescribed
Quotes taken from NEPAD in Brief. Accessible from: http://www.touchtech.biz/nepad/ Also see the official NEPAD documentation adopted in Abuja in October 2001. Accessible from http://www.dfa.gov.za/events/nepad.pdf 75 NEPAD: Health Strategy Executive Summary. Adopted at the First Ordinary Sessions; Conference of African Ministers of Health, 26-30 June 2003, Tripoli, Libya. Page 3. Accessible: http://www.touchtech.biz/nepad/files/documents/117.pdf 76 Human Resources Development Programme NEPAD Health Strategy. 29/01/2003. It notes that The situation of traditional medicine remains weak in most countries because of the insufficient evidence of safety and efficacy of traditional medicines; lack of knowledge of attitudes, practices and behaviours in traditional medicine; lack of coordination between traditional medicine and the rest of the health system; inadequate documentation; lack of protection of intellectual property rights and endangered medicinal plants (page 4). Accessible: http://www.touchtech.biz/nepad/files/documents/115.pdf
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for opportunistic infections, as well as with anti-retrovirals. This information needs to be summarized in a fact sheet and distributed widely. It is important that TAC incorporates this information into its Treatment Literacy programmes, while traditional healers need to do the same for their programmes; There is a need for the formal recognition of traditional healers as HIV/AIDS counsellors, if they have fulfilled the necessary requirements. Traditional healers have an important part to play in DOTs for TB and the use of anti-retroviral therapy; It is important to recognize the value and complexity of intellectual property rights in relation to indigenous knowledge. All forms of indigenous knowledge should be protected from theft and unauthorized use for monetary gain.

Thus - if the systems of traditional and Western medicines and healing are equalised and the same strict standards of safety, efficacy, professionalism and ethics are applied to both, no unfair discrimination towards traditional healing should be tolerated.

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Aligning Traditional Healing and Human Rights A Checklist

Everyone has a right to human dignity

Traditional healers and their patients have to be treated with respect and dignity. Patients must not be subjected to degrading rituals or procedures.

Everyone has a right to privacy

Traditional healers must respect their patients confidentiality and not disclose any medical information to third parties without their clients express consent.

Everyone has the right to equality and non-discrimination

Traditional healing should not experience discrimination in relation to the practice of Western medicine, where it fulfils the same standards of efficacy, safety, accurate patient information, professionalism and ethics.

Everyone has the right to freedom of conscience, religion,

expression, thought, belief and opinion and the right to culture

Traditional healers and their patients may not be prevented from expressing or practicing their beliefs and traditions, except in cases where it causes undue suffering or infringes on the human rights of others.

Everyone has the right to the freedom of trade, occupation and profession

Traditional healers must be free to practice their profession.

Everyone has the right to have their environment protected

It is important that in preparing their medicines, that traditional healers do not contribute to environmental degradation, while they should promote conservation and secure ecological sustainable development.

Everyone has the right to access to health care services

Everyone should be able to make use of adequate, safe and beneficial health care assistance, and be able to elect being treated by traditional healers.

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